Authorization for Release of Protected Health Information (PHI) Form

Elite Health Solutions ~ Sandy Springs, GA

I, the above named Releasor, hereby authorize Elite Health Solutions, to release the below checked information;

I, above-named Releasor, authorize the above selected PHI to be released to Life University Athletics Department; specifically to the Director of Athletic Care (Robert Dubuque or designee), via electronic email communication. This includes all appointment-related information and results reported from the reference laboratory.

• This authorization shall remain effective from the time of execution of this document for a period of no greater than one-month from the date of signature.

• By signing this document, I hereby declare that I understand and acknowledge that I am giving authorization to the use and/or disclosure of my protected health information as described and for the purpose specified above.

• I am signing this authorization voluntarily. I understand that I have the right to withdraw my permission or withdraw my authorization at any time by writing. In case I withdraw my authorization, I understand that any benefits, treatment, or eligibility shall not be affected.

• Further, I understand that this authorization may not further be used by the person or entity to whom my medical records are to be disclosed, to use or disclose the said information to another unless otherwise permitted in writing or unless such intended disclosure is required or permitted by law.